US embassy cable - 05SOFIA1962

UNCLAS SECTION 01 OF 04 SOFIA 001962 
 
SIPDIS 
 
DEPT FOR EUR/NCE, SCOTT BRANDON 
 
E.O. 12958: N/A 
TAGS: TBIO, ECON, PREL, SOCI, BG, KSTH, WHO 
SUBJECT: BULGARIA'S PREPARATION FOR AVIAN FLU 
 
REF:  STATE 206992 
 
1. (U) The following is post's response to reftel: 
 
A) PREPAREDNESS/COMMUNICATION 
 
--Does the government have a preparedness plan/strategy for 
preventing avian flu from becoming a pandemic and containing 
a pandemic once it occurs?  If the country has a strategy, 
how capable is it of implementing it? 
 
2. (U) The Bulgarian government has developed a preparedness 
plan for preventing and containing avian flu.  In the area 
of veterinary affairs, two major official documents regulate 
the surveillance and control of AI.  These documents are the 
"Surveillance Program for Newcastle Disease and Avian 
Influenza" (Dated 2000) and Ordinance #47 (Dated November 
2002), "The Measures for Prevention and Fight against the 
Avian Influenza."  Both documents were approved by the 
Minister of Agriculture and Forests and have been 
implemented since 2001-2002.  Ordinance #47 has been 
harmonized with the EU Directive 92/40.  The Surveillance 
Program for Newcastle Disease and Avian Influenza is under 
revision and will be updated in 2006 in accordance with the 
latest EU directive on Avian Influenza 464/2005. 
 
3. (U) The GOB also has drafted a National Pandemic Plan, 
which is currently before the cabinet, and established a 
national AI crisis task force. The task forces meets weekly 
and includes experts from 7 ministries as well as 
independent scientists. The major problem, however, is that 
the country does not have the financial resources to 
implement their plan.  The national task force requested 7-8 
million leva (4-5 million USD)from the 2006 budget, but will 
receive only 2.5 million leva (1.5 million USD), according 
to the recent draft budget. The Health Ministry, which will 
get 2 million leva (1.2 million USD) rather than the 5 
million leva (3 million USD) requested, has said that 
without appropriate funding, they will not be able to 
respond to an AI outbreak. 
 
--How truthful will the government be in reporting the scope 
of any disease outbreak among people?  Among animals?  What 
incentives could be offered that would likely result in more 
transparency? 
 
4. (U) We have no reason to doubt the government's 
willingness to report any cases of avian flu among the human 
population.  Many officials have told us that an outbreak of 
bird flu in Bulgaria is inevitable given the number of 
confirmed cases in neighboring countries.  The National 
Avian Flu Crisis Task Force has requested 1 million 
Bulgarian leva (approximately 670,000 USD) from the Finance 
Ministry to compensate farmers for culled birds for the rest 
of 2005.  An additional 1.7 million leva (1 million USD) has 
been requested for 2006.  This money should encourage 
farmers to truthfully report an outbreak of disease in their 
livestock by providing protection against personal economic 
ruin.  Additional financial compensation for farmers would 
be the best incentive to ensure greater transparency in 
reporting. However, the Agricultural Ministry is slated to 
receive only 500,000 leva (300,000 USD) for AI, which is 
insufficient. 
 
--Where does preparing for an avian flu human pandemic rank 
among government priorities?  Who and what would most 
influence the country to give the issue a higher priority? 
Who is the key "go-to" person, office or department (i.e 
Minister for Health, Prime Minister, etc.) for USG officials 
to engage on this issue? 
 
5. (U) Preparing for an avian flu human pandemic has ranked 
moderately high among the government's priorities, 
particularly after cases of avian flu were confirmed in 
neighboring Turkey and Romania.  However, public interest 
and pressure on the government to develop a response has 
subsided over time and the issue has become less of a 
priority for the government. AI still is a key priority for 
the Health and Agriculture Ministries. A confirmed case of 
avian flu in Bulgaria would be the strongest catalyst 
encouraging the country to make AI an even higher priority. 
The Health Minister Radoslav Gaidarski and Agriculture 
Minister Nihat Kabil are the two officials primarily 
responsible for leading Bulgaria's Avian Flu response. 
Gaidarski heads the National AI Crisis Task Force and Kabil 
is his deputy.  The Health Ministry and the National 
Veterinary Service in the Agriculture Ministry are the lead 
bodies charged with Bulgaria's response effort. Prime 
Minister Sergey Stanishev, however, is the most important 
person who can energize the work of the ministries, find 
badly-needed funds, and insure AI remains a high priority. 
 
--Have national laws been reviewed to ensure that they are 
consistent with the international health regulations and do 
not pose barriers to avian influenza detection, reporting, 
containment, or response? 
6. (U) Most of the laws Bulgaria utilizes for AI 
surveillance and prevention have been harmonized with EU 
directives and are consistent with international health 
regulations.  Bulgaria is using EU and WHO directives as the 
basis for its rapid response to AI. 
 
--Is the host country already working with international 
organizations or other countries on the avian flu issue? 
Are government leaders likely to ask for assistance from the 
U.S. or other countries?  Would government leaders be 
receptive to messages from U.S. leaders through a bilateral 
approach, at a multilateral forum such as the UN (WHO, FAO, 
etc.) or APEC, or through bilateral contacts by a third 
country?  What would the country want from the U.S. in 
return for its efforts? 
 
7. (U) The vet service regularly coordinates its activities 
with the WHO, OIE and to some extent FAO.  This is a working 
relationship that was established in the past.  Bulgaria is 
not part of the IPAPI, as they depend on guidance from the 
EU.  One example of Bulgaria's cooperation with the EU on 
this issue was a two-day AI simulation exercise held near 
the town of Vratza in August with the support of TAIEX 
bureau (Technical Assistance and Information Exchange) of 
EU.  The exercise was done after a two-day avian influenza 
seminar, in which two EU experts trained 28 regional 
Veterinary Services chief animal health officers, the New 
Castle Disease and Avian Influenza reference laboratory 
specialists, and veterinary staff from the headquarter of 
the National Veterinary Medical Services (NVMS). A team of 
two EU experts met with the GOB on October 18-20 to assess 
Bulgaria's assessment capabilities and readiness on AI. 
They felt Bulgaria was taking adequate measures, but 
reportedly could not offer any direct assistance--other than 
consultancy services and possibly some testing kits--because 
Bulgaria is not yet an EU member. 
 
8.  (U) The GOB has requested U.S. assistance for AI and we 
have facilitated the visit of a U.S. academic specialist to 
consult with the National Veterinary Service on diagnosing 
AI.  USAID also is trying to find funding for supplies and 
equipment. According to the National Veterinary Service and 
Ministry of Health we (USDA Foreign Agriculture Services and 
USAID) were the first bilateral mission to meet with them 
and listen to their concerns and discuss needs.  Bulgarian 
officials are likely to be most receptive to messages from 
US leaders that are delivered in conjunction with the EU 
given the country's current focus on EU integration. 
Otherwise, Bulgaria would likely be receptive to high-level 
bilateral approaches. 
 
--Does the country currently administer annual flu shots? If 
not, might it consider doing so?  What is the production 
capability (i.e. how many doses of the annual trivalent flu 
vaccine can the country make) for the human influenza 
vaccines in the country?  Does the country produce influenza 
vaccine for poultry and if so how much?  If the country is 
developing an H5N1 vaccine, where is it in production and 
testing?  Any licensing issues?  Is there a liability shield 
for foreign makers/donors or vaccines?  If not, any 
prospects of one being enacted? 
 
9. (U) In cases of emergency, vaccinations (conventional 
anti-virus vaccination) will be provided to those people 
surrounding the area around the outbreak.  Vaccination of 
poultry can be done in the same area, but only after 
explicit instructions from the Agriculture Ministry and 
should be done with an EU origin vaccine.  Bulgaria is not a 
producer of influenza vaccines for either humans or poultry. 
The Nation Veterinary Services indicated they would need 
1000 regular flu vaccines and 1000 Tami flu doses for their 
front line staff to protect them in the event of an 
outbreak.  The Health Ministry has requested 3.5 million 
leva (2.1 million USD) for protective vaccines for 2006, 
which would cover 5% of the population (high risk 
population).  None of these funds are for the National 
Veterinary Services' front line staff. 
 
--How well informed is the population about the avian flu 
threat and about measures they should take to mitigate the 
threat?  What mechanisms are available for providing 
additional information to the population, particularly in 
rural areas and how effective are these measures? 
 
10. (U) The national media is very active in keeping the 
general public aware of issues surrounding AI.  Daily 
reports have been published on all regional and national 
issues related to AI.  Most newspapers and radio promote 
interviews with researchers and experts about the nature of 
AI and the precautions which can be taken.  The emphasis has 
been both on the effects to the poultry industry and related 
feed/grain industry and on the human health side of the 
problem.  Some publications have been overly strident in 
their reporting and caused some panic among the public.  In 
October a dead bird found on the capital's main shopping 
street resulted in the area being sealed off and traffic 
being diverted during the evening rush hour. 
 
11. (U) Additionally, 40,000 copies of a special AI pamphlet 
were developed and distributed to mayors, hunters, the 
poultry industry, and veterinarians.  The pamphlet briefly 
describes the clinical signs, the disease mechanism and 
diagnostic methods of AI, as well as measures which should 
be taken for prevention, surveillance and the fight against 
AI.  However, the pamphlet does not provide complete farm 
management information to the poultry industry nor what 
recommendations, practical steps and specific precautions 
should be taken to keep the farms safe.  The National 
Veterinary Service needs further financial assistance for 
development, printing and distribution of more and improved 
information materials as well as support for covering a 
wider audience. 
 
B) SURVEILLANCE/DETECTION 
 
--How capable are the medical and agriculture sectors at 
detecting a new strain of influenza among people or animals 
respectively?  How long might it take for cases to be 
properly diagnosed, given other endemic diseases?  Can 
influenza viruses be subtyped in the country, if so by who, 
and if not where are they sent?  Does the country send 
samples to a WHO/EU/U.S. reference laboratory? 
 
12. (U) The medical profession has a limited ability to 
detect new strains of influenza in people.  The Ministry of 
Health has issued instructions to the general practitioners 
for better diagnosis of influenza.  However, like many 
countries, the flu is underreported in Bulgaria.  In order 
for a doctor to formally diagnose the flu, she or he must 
draw two blood samples from the patient and submit them to 
the country's CDC.  The length of this process and the cost 
encourages doctors to formally avoid diagnosing and 
documenting a case of the flu.  Doctors tend to list another 
symptom and then prescribe a general medication that will 
address the flu symptoms. 
 
13. (U) Bulgaria has a laboratory in each district city for 
diagnosing human samples.  Most of these labs are not 
equipped for all diagnostic options.  There is one reference 
lab in Sofia at The National Center for Infectious and 
Parasitic Diseases which covers all diagnostic options. 
There is only one lab in Sofia for diagnosing animal 
samples.  Diagnosis typically takes 5 to 7 days. Bulgaria 
has a limited ability to subtype viruses. The country sends 
its samples to Waybridge, England, for referencing. 
 
--What are the critical gaps that need to be filled in order 
to enhance the country's disease detection and outbreak 
response capabilities?  What is the country's greatest need 
in this area from the U.S. or international organizations? 
 
14. (U) Bulgaria has trained people and one reference lab in 
the capital, Sofia, where they have carried out monitoring 
and surveillance simulations in the past.  However, while 
they have the technical capability, they sorely lack 
equipment.  There is a need for a lab in the northeast at 
the migratory corridor or at least a mobile lab to respond 
quickly to testing requirements.  Currently there is up to a 
10 hour delay getting samples from the field to the only lab 
in the country in Sofia.  Additional funds are needed for 
transportation and field consumables.  The Bulgarians would 
like to have, at the minimum, a mobile laboratory to be 
situated in the northeast part of the country and have their 
Sofia lab upgraded.  In addition to laboratory equipment, 
the current lab staff(only 5 people) need better training in 
the practical use of this equipment.  New equipment is 
needed and new trained staff should be hired as well in case 
of an outbreak. 
 
C) Response/Containment 
 
--Does the country have a stockpile of mediations, 
particularly of antivirals, and if so how much?  If some has 
been ordered, how much and when is it expected?  Does the 
country have a stockpile of pre-positioned personal 
protective gear? 
 
15. (U) The country does not have a stockpile of antivirus 
vaccines or personal protective equipment for the veterinary 
and medical staff exposed to risk on a daily basis. 
Currently available stocks are in limited quantities and are 
sufficient for regular implementation of the AI surveillance 
program and regular lab testing.  There is no money to 
purchase these items and the need is urgent. The lack of 
resources make it impossible to stockpile vaccines, 
protective equipment, antibiotics, etc.  To the best of our 
knowledge the Ministry of Health intends to purchase 200,000 
units of Tamiflu and 200,000 units of Remantadine, if they 
receive the approval of the Council of Ministries for funds. 
 
--What is the rapid response capacity for animal and human 
outbreaks?  Are there guidelines in place for the culling 
and vaccinations of birds, disinfection of facilities, and 
limitations on animal movement? 
 
16. (U) The GOB is using directives from the EU and WHO as 
guidance when mounting a campaign to respond to a human 
outbreak of H5NI influenza.  It is a phased response with 
trip wires recommended by the EU and WHO.   Within 24 hours 
the healthcare professionals can be mobilized.  A number of 
hospitals have been designated as first responders.  The 
Ministry of Health is prepared to ratchet up an information 
campaign should the specific trip wire be activated. 
Implementation will depend on the number of people affected. 
For a small outbreak of up to 60 people, the primary 
hospital will be the new military hospital, which has 60 
beds, new ventilators and isolation rooms.  Should the 
pandemic get out of control, Bulgaria, like many countries 
will find itself short of beds, diagnostics, anti-viral 
medication, and protective gear. 
 
17. (U) The veterinary service currently is at a high alert 
level and ready for an emergency situation.  The service's 
response is based on international directives with set 
guidelines for culling animals and disinfecting areas. The 
service has practiced its response to AI in simulated 
exercises.   In a case of an outbreak, a quarantine zone 
will be established within 3 and 10 kilometers of the 
infection, depending on the situation.  In case of highly 
contagious diseases with important economic and social 
effects, such as AI, the Veterinary Service acts in 
coordination with police and military units which are placed 
at the quarantine zones and control the movement of people, 
vehicles and products. 
 
18. (U) The capacity of the veterinary service is limited in 
terms of both sufficient lab staff and lab equipment. 
Contingency planning does not meet the requirements for 
larger scale outbreaks.  Sampling is not risk based, the 
number of samples submitted exceeds the capacity of the 
reference lab and thus the lab response is rather slow. In 
case of an emergency situation or a confirmed outbreak, the 
number of lab personnel will be inadequate to process the 
expected higher number of samples. 
 
--How willing and capable is the government of imposing 
quarantines and social distancing measures (closing schools, 
public gatherings, mass transit)?  Would its military 
enforce quarantines? 
 
19. (U) The government is capable of imposing quarantines on 
a smaller scale and has some experience in this regard from 
past influenza epidemics.  A larger scale outbreak, however, 
would be a challenge for Bulgaria given limited resources 
and insufficient infrastructure. 
 
BEYRLE